CPT Code Spotlight - Modifier 59

Modifiers can be extremely confusing, especially when it comes to deciding which one to use. Selecting the wrong one can lead to payment denials from insurance companies and puts practices at risk for payers requesting refunds.

What is Modifier 59?

Modifier 59 is one of the most misused and mislabeled modifiers. It's used when two or more procedures are performed during the same visit but for different reasons and/or on different parts of the body. They are distinct and independent from other non-E/M services performed on the same day.

When to Use Modifier 59

There is only one main reason to use modifier 59. That reason is the two or more procedures performed on the same day are independent from one another. It can also be used if there's not another appropriate modifier that can be used to describe the relationship between the two procedures. If another modifier works better to describe the relationship, that modifier should be used instead.

Examples of When to Use Modifier 59

For the first example, we'll hang with Marissa. Marissa had a benign lesion on her big toe removed. During this same session, her physician debrides a toenail on a different toe. This would be considered modifier 59 because Marissa had two different sites operated on in the same session.

For the second example, we'll hang with Jose. Jose visited the hospital to have a cardiovascular stress test done. Later that same day, he also had an echocardiogram (ECG). Although they appear to be related, the same-day session overrides this. It's also a non-E/M procedure that didn't occur in the post-operative period.

When NOT to Use Modifier 59

Sometimes, it can be easier to know when not to use a specific modifier. Below are examples of what wouldn't constitute the use of modifier 59:

• The two procedures are performed on the same site, organ, or system
• The two procedures are not separate or distinct
• Another modifier describes the procedure better
• The procedure is an E/M service

Compared to 24, 58, 78, and 79, modifier 59 is the most misused and mislabeled. The biggest takeaway is there is a same-session or same day procedure of two separate things that are non-E/M related.